Ever heard the term ‘designer vagina’? This generally refers to a certain type of cosmetic surgery, not to the vagina itself but to the ‘inner lips’ (or labia minora) of the vulva. Surgery here involves removing tissue from and reshaping the appearance of the labia minora- in other words to ‘trim’ it. Many people with vulvas have a labia minora that protrudes so that it appears visible – therefore however large this is it is likely to be ‘normal’. Additionally, in young people biological changes occur during puberty that can change the appearance of the inner labia. For this reason it is often recommended by the NHS that those under 18 do not get this type of surgery. However, there seem to cases of children having labiaplasties. According to one report over 200 people received labiaplasty procedures funded by the NHS in 2015-2016. We know that people with visible labia are more likely to think that their genitals look ‘abnormal’ than those without, even though both are equally common (Lykkebo et al, 2017). Some accounts have blamed this on the prevalence of seeing only vulva with neat and invisible labia minora. Whatever the cause, the desire to have this type of surgery seems increasingly common with a 45% rise seen in labiaplasty numbers worldwide between 2015 and 2016.
Pubic hair and body positivity can be a tricky issue. On the one hand, people absolutely have the right to cut, shape, dye, remove or in any other way sculpt their own personal body space! I get how it can be liberating and a way of taking control of your own body and quite literally shaping your intimate identity.
On the other hand, there seems to be a growing repulsion for body hair that isn’t manicured. A dislike for ‘natural’ hair, particularly (but not exclusively) when it comes to vulvas. Some people specifically find it ‘unhygienic‘. This despite the fact that pubic hair, like the hair on your head, has specifically protective functions.
So trim and go as bare as you dare around your nether regions if you want to. But maybe think about why your doing it!
Rounding off the year, let’s have a look at penises! We (the societal ‘we’) tend to be a bit more familiar with the constituent parts than we are with vulvas…
Glans: This is the tip or ‘head’ of the penis.
Foreskin: This is a fold of skin that covers the glans of the penis. It can be removed, either at birth or later in life, for either medical or cultural reasons in a process called circumcision. Rates of this practice vary across the world and it isn’t as common in the UK as in other parts of the world.
Urethra: The opening of the penis. Semen, urine and discharge can leave the body here. As with discharge from the vagina, this can be normal. Changes in the discharge (e.g. smell or colour), especially when accompanied by other symptoms (pain, itchiness) can however indicate something’s not quite right and might need checking out.
Shaft: This is the main bit of the penis. Internally are found the tubes that carry urine and semen out of the body, as well as blood vessels supplying the penis – this is part of the mechanism that causes the penis to become hard and bigger during an erection.
The average penis size is 9 cm when not erect, although there is a fairly large and health variation in this.
We seem to sometimes fall in to the habit of talking about ‘discharge’ from the vagina as if it’s always bad thing- for example as a sign of an infection. It can be easy for forget that it’s also a healthy part of how this bit of your vulva works. The vagina produces a mucousy discharge that helps keep it clean and protects from infection. But what is it ‘meant’ to look like?! Healthy discharge should be:
SMELL – not strong and/or unpleasant.
COLOUR – clear or white.
CONSISTENCY – thick and sticky or slippery and wet.
It’s perfectly normal for it to vary a bit with age and during different bits of the menstral cycle, but as long as it’s within these parameters, it’s all perfectly normal… so now you know!
The information here is adapted from an exercise from Sexplain UK, used as part of their SRE lessons. In short, it involves using play dough to build genitals. This exercise can be used to teach people about external genitalia (both penises and vulvas). As an arts and crafts activity, it can be fun and engaging and help to give something concrete to talk around in terms of things like physiology, variation and health. I have also included the recipe I use for homemade play dough.
To make your dough.
2 cups plain flour
1 cup of salt
2 teaspoons cream of tartar
1 tablespoon of vegetable oil
2 cups of boiling water
Something to colour the dough with (optional) such as food dye, paint powder, or a crushed soft pastel
Put all of the ingredients except for the water and colouring in to a large mixing bowl. Boil water and add this to the mix whilst still very hot. Mix immediately using a wooden spoon. Once the mixture is cool enough to handle, put some flour on a surface and lightly knead the mixture for a short time. If you are adding colouring, now knead this in until the dough is roughly all the same shade throughout.
Make sure the dough is left uncovered until it is cool, then cover in an airtight container. It should last for about a week. This recipe makes enough for about twelve people if doing the exercise below.
So, all foetuses have the same general genital structures, regardless of what sex they will become. They then typically (but not always) differentiate in to either a penis or vulva. These are the external genitalia (i.e. the bits you can see).
We’ll look at vulva first, as this is the one people tend to find a bit trickier.
Take your ball of play dough and divide it in to four pieces. With one of these quarters, make a left or diamond shape:
This is the vestibule of the vulva.
Next, take another quarter and roll it in to a sausage shape, about the length of one side of the vestibule and attach it to one side:
This is the labia majora, the fatty tissue that covers the whole vulva and tends to be covered in hair after puberty. Complete it by making another sausage to attach to the other side:
Next, divide the last quarter in to two. With one piece, make a smaller sausage to attach inside one side of the labia majora. This can be flattened if you like:
This is the labia minora. In about half of people with vulvas, the ‘inner lips’ of the labia minora sit outside of the bigger ‘outer lips’ of the labia majora. Let’s complete these. As with the labia majora, it’s not a problem if they aren’t exactly symmetrical:
Next, let’s make a very important structure: the clitoris. Either take a little ball of extra dough, or pinch a piece off from your existing structure:
The bit we can see here only represents the external part – it extends to be a much bigger structure internally. The clitoris is made of very sensitive tissue, with lots of nerve fibres. Some people find it arousing or stimulating when touched gently.
To complete, let’s make the ‘holes’ in the vulva. Get people to guess how many ‘holes’ the vulva contains (guesses I’ve heard range from one to twenty!). For this model, we’ll be looking at two (you can explain that some people talk about a third, the anus, which is actually outside/below the vulva). The first is about a third of the way down and can be marked with a finger or a pencil:
Get students to guess its name – the urethra, and it’s function – carries urine away from the body. It is separate from the next hole we’re going to make. This hole is nearer the bottom of the vestibule and can be marked by making a hole all the way through:
Again, you can get people to guess the name (vagina) and point out that this is the name people often use (incorrectly) to refer to the vulva. You can talk about things that come out of the vagina – i.e. blood (periods), babies and discharge (either healthy or a sign of otherwise, such as thrush or bacteria).
Next, we’ll make a model of a penis.
This time, divide the dough in to two pieces. With the first piece, make a sausage shape:
This represents the shaft of the penis. We can then make a little distinct area by marking out the end:
This is the glands of the penis, which tends to be more sensitive than the shaft. Next we can make a hole in the end (with a pencil or finger). This is the urethra or the penis. Three things can come out of this – urine, ejaculation or discharge.
Give people the option of making a foreskin – pinch off a little bit of dough and fashion in to a thin rectangle to cover the glans. This is a good point to talk about hygiene – e.g. washing with water and changes during puberty, as well as circumcision.
Next, we’ll finish off with making the testicles (scrotum). There is a good chance that students will already have made them with the other half of the dough by making two balls and attaching these to the base of the penis:
This is fine and validate this. Also explain that you can make them from a ‘teardrop’ shape and attach that. You can talk about the misconception that ‘balls drop’ (i.e. they get bigger and hang lower after puberty, but don’t actually ‘drop’ further out of the body).
It can be a nice idea to get the students to look at and reflect on how different all of the bits are. Lots of them seem to ask what ‘normal’ is – this can be a good place to point out that this is something that is highly individual.
We often talk (briefly) about the concept of it being possible to be biologically ‘intersex’ – i.e. it is possible to have someone who doesn’t have external genitalia that fall neatly in to either of these categories.
It can also lead on nicely to talking about internal genitalia and reproductive functions.
My weakest area at med school was definitely anatomy. I enjoyed it though. Each week, we would go to the anatomy suite where the cadavers were kept and I would learn another thing I was previously mistaken about. The relationship between what we see and understand on the outside and what and where it is on the inside is often not straightforward.
The stomach, for example, is not the low down bit of the abdomen people hold when they have ‘bellyache’ – that’s more like bowels. This is part of the gut, but with has a distinct and different function. What a lot of people think of as the ‘vagina’ (the passage from the external body to the womb) would actually be better described as the ‘vulva’. In my experience, these misconceptions are rife in ideas about our reproductive organs. Let’s have a look at some of the internal xx anatomy…
Vagina: a passage leading from the outside to internal parts. It’s made up of muscular, stretchy tissue that can deform and accommodate various things (tampons, fingers, foreign objects, a baby…).
Cervix: the lower bit of the womb. Roughly tube shaped and typically around 2-3cm long. It has a hole (the cervical ‘os’) which leads from the vagina to the womb. It can change shape, size and consistency under hormonal control – e.g. getting smaller and opening during childbirth.
Uterus: Or ‘womb’. This is where a baby can grow. Sits just behind the bladder in non-pregnancy. The lining of this cavity is called the ‘endometrium’. It is the endometrium thickening and then shedding that is experienced as periods. The top bit of the uterus is called the ‘fundus’.
Fallopian tubes: connect the uterus to the ovaries. Also called the ‘salpinges’ or a ‘salpinx’. Each one ends in a ‘fimbria’. This is a little fringe of tissue that helps convey eggs in to the tubes from the ovaries.
Ovaries: whitish lumps of tissue where eggs are released from. They also produce hormones so have an important endocrine role.
All of these structures sit quite low down in the abdomen. Sometimes problems that feel like they are coming from this reproductive tract can be mistaken for problems with the bowel and vice versa. We’ll have a look at some of these problems another time…
The inspiration for this one came from a pub conversation. It’s time for…
The hymen is a often described as a ‘membrane’. It is membranous tissue, but this can lead to some confusion-
This is called an ‘imperforate hymen’. The main reason it needs treatment (i.e. surgical removal) is that it means that menstral blood cannot drain during a period.
So, as with many aspects of genitals, individuals can be VERY different and this is completely normal.
References (a note):
When I have an idea for something, I usually start by looking at some standard Gynae textbooks and then try to find reliable looking online sources (e.g. NHS, clinical guidelines). They failed me somewhat on this topic. I’ve found a teeny tiny amount of information from my textbooks (mainly on imperforate hymen). This is basically a way of explaining why my main source is a wiki page (here)!
Now let’s finish our exploration of the vulva with something a little more than skin deep: the bartholin’s glands. These are two paired glands that lie within the vagina. Their position is roughly shown here: as the two little blue lumps. They lie just inside the entrance or ‘introitus’ of the vagina, as shown here. They can’t be seen directly. However, sometimes they can become infected and inflammed. This can cause pain and swelling as pus collects and is unable to drain – a condition known as a bartholin’s cyst or abscess. Treatment includes antibiotics to target an infection, or drainage and insertion of a ‘word catheter’ – a piece of tubing that can be placed and inflated to prevent pus from reforming and allowing the tissue to heal.
Lots of people seem unsure about what makes up typical XX genital anatomy – the uterus, ovaries and vulva ensemble. Unlike penises, the majority of the bits that ‘do’ something are hidden – either internally or amongst lots of indistinct lumps that are hard to view on self-examination.
Let’s start with the external genitalia – the vulva. Sometimes people refer to it as the ‘vagina’, although this is the name for a specific part of the vulva.
This is my version of a typical textbook diagram:
To orientate yourself, imagine that the person you’re looking at is lying on their back, bottom on a surface below and legs akimbo. You are standing at the foot end, looking ‘into’ the vagina and at the vulva from here. The person’s bum is at the bottom of the picture and any hair covering the vulva at the top of this image. Without pretty sound gymnastic skills and an ingenious mirror system, it is unlikely that anyone has ever seen their own vulva from this angle. However, it is the view that a doctor or nurse (for example) would obtain to do a gynaecological exam, which is probably why it gets used in diagrams so often.
The bits that make up the vulva are as follows:
Clitoris: A bundle of sensory nervous tissue. It can feel good to touch or otherwise stimulate here. In Alice Walker’s novel ‘The Colour Purple’, Shug refers to her clitoris as her ‘little button’ that gives her pleasure.
Urethra: An opening for urine to pass from. A tube (sometimes with a bag) called a ‘catheter’ can be passed here to drain wee in some circumstances.
Labia Majora: The ‘big lips’ – the bigger folds of tissue that cover the front of the vulva. If a person with a vulva were standing up, walking around, this is probably the only bit you could make out. All other bits mentioned here would be hidden by it and the legs.
Labia Minora: The ‘little lips’ – smaller folds of tissue surrounding the inner part of the vulva. Although there is relatively less tissue here than the labia majora, there is a huge amount of variation in the size and shape of the labia minora between individuals. Surgery to reduce the amount of tissue here is called ‘labiaplasty’ and it is usually this that people mean when they refer to ‘designer vaginas’. This area is not really called the vagina though…
Vagina: This is the passage in to the body and the rest of the reproductive tract (i.e. the cervix and womb). A penis (or other objects!) can go in and believe it or not a baby can come out of here.
The area within the labia minora in to which the urethra and vagina open up can be called the vestibule. The area between the vulva and the anus is called the perineum.